If an IV infusion seems to have delivered more than expected since 0700, what is the initial nursing action?

• A. Increase the flow rate
• B. Call the physician
• C. Check tubing and infusion for obstruction
• D. Record as normal

Answer: (C)

When IV delivery is higher than expected, the first step is to inspect the IV setup for mechanical issues. Check the tubing for kinks, bends, or clamps that might be occluding flow or causing an unintended surge, and verify the line is clear and connected correctly. Also quickly confirm that the pump settings and the IV solution match the order. Many times a simple tubing obstruction, a closed clamp, or a misconnection explains unexpected delivery and can be corrected right away, preventing unnecessary changes to the rate or further interventions. If the setup checks out, then re-evaluate the rate and involve the physician if the discrepancy persists.